Healthcare professionals tend, like everyone else, to make some choices based on habit or training. The web site Choosing Wisely encourages physicians and patients to question some of those routine choices.
Choosing Wisely ® aims to promote conversations between physicians and patients by helping patients choose care that is:
- Supported by evidence
- Not duplicative of other tests or procedures already received
- Free from harm
- Truly necessary
One of the lists on the site is from the Critical Care Societies Collaborative; five things physicians and patients should question:
1. Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.
2. Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 g/dL.
3. Don’t use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.
4. Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.
5. Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.
Read the explanations for these five recommendations here:
There are numerous benefits to applying blood conservation principles in patient care, most often referred to as Patient Blood Management . For example:
- Allogeneic transfusion is emerging as a potent risk factor for many complications commonly seen in hospitalized patients. – Mt. Sinai Journal of Medicine http://onlinelibrary.wiley.com/doi/10.1002/msj.21290/full
- Donated blood doesn’t transfer oxygen from the blood to the body tissues as effectively as the patient’s own blood does. - Forbes http://www.forbes.com/sites/marijkevroomendurning/2013/08/14/blood-transfusions-after-surgery-multiple-units-of-blood-add-to-infection-risk/
- An analysis of more than 31,000 patients who underwent isolated coronary artery bypass grafting (CABG) surgery… showed that receiving one or more blood transfusions conferred a nearly threefold increased risk of operative mortality… – Internal Medicine News http://www.internalmedicinenews.com/index.php?id=514&tx_ttnews%5Btt_news%5D=57604&cHash=5eb08f03e2
- In 2010 Englewood Hospital and Medical Center (Englewood, New Jersey) received nearly $4.7 million in federal funding to train military and civilian physicians in bloodless surgery and other medical procedures. – NorthJersey.com http://www.northjersey.com/news/012910_Englewood_Hospital_to_train_military_others_in_bloodless_surgery_techniques.html
- Patients receiving too many blood products… are more likely to experience medical complications, including infections and organ damage. A growing number of hospitals hope to reduce these risks by limiting their use. - USA Today http://www.usatoday.com/story/news/nation/2013/12/08/hospitals-look-to-limit-transfusions/3905353/
- The work group reached consensus on the need to identify and remediate the drivers of the variability in transfusion practice to further optimize practice in line with available clinical trial data. – The National Summit on Overuse, 2012 http://www.jointcommission.org/assets/1/6/National_Summit_Overuse.pdf
Experienced Caregiver Shares 3 Tips for Injecting Humanity into an Often Cold & Arbitrary Heath-Care System
As a well-traveled, well-educated couple who spent most of their lives in New York City, Philip and Ruth Barash had witnessed and experienced much as they approached their golden years. A savvy New York couple, they’d learned to anticipate challenges.
Philip was a U.S. Army veteran who’d served in the Korean War and later became an attorney; Ruth’s education and experience includes philosophy, art, real estate, public relations and executive-level civic work. But one problem they didn’t foresee was navigating their own country’s health-care system. In the most prominent city of the wealthiest nation on the planet, how bad could it be?
“Philip’s health problems began in 1988 and steadily continued until his death in 2012,” says Barash, who shares her health-care experiences in a new book, “For Better or Worse: Lurching from Crisis to Crisis in America’s Medical Morass,” ( http://forbetterorworsebook.com /).
“We were in and out of doctors’ offices, hospitals and emergency rooms a lot, and I was shocked by the lack of compassion we frequently encountered, as well as the number of health-care professionals who simply are not good diagnosticians.”
Barash’s cautionary tale traces her husband’s long death through a medical journey fraught with mismanagement and excess, useless interventions and a sometimes complete disregard for pain – even when there was no hope of healing.
“The art of intuitive, compassionate health care is dying as doctors rely more on technology and are guided through an arbitrary template established by insurance company policies,” she says.
Barash discusses some of the lessons she has learned while navigating overcrowded and dingy emergency room lobbies, callous staff and tech-absorbed doctors.
• Have an advocate! Through the years of Philip’s health problems, we encountered extreme kindness, thoughtfulness and high intelligence; we were also confronted with arrogance, indifference and self-serving staff during some of the worst moments. As hard as it was for both of us, we always knew we had each other. If and when you find yourself requiring medical assistance, avoid going it alone; it will be exponentially more difficult, and your chance for survival will exponentially decrease.
• Ask what benefits a proposed treatment will have. We all like to think we have good doctors, and that if we’re hospitalized, we’ll be competently cared for. We also like to think Santa will bring us nice presents if we’ve been good children. Realize that invasive and expensive tests are often not necessary; in fact, they often make things worse. Be as skeptical about a procedure proposed by a doctor as you would by any salesman.
• Don’t get sick! While this may seem like a facetious bit of advice, since we all succumb to illness at some point – it’s actually a sincere sentiment. Do not take your health for granted; do not think “they” will invent a quick fix between now and the time you find yourself in need of serious medical attention. Unnecessary health risks such as smoking; illegal drug use; excessive alcohol intake; and a diet filled with sugar, salt and fat will take you sooner rather than later to the hellish journey known as the U.S. health-care system.
About Ruth Fenner Barash
Ruth Fenner Barash studied philosophy at City College of New York and did graduate work at the University of Chicago. In 1958, she met and married Philip Barash, a private practice attorney. She went on to work in public relations and real estate, served education and civic organizations at the executive level, and taught art in various media. Her long marriage was a “harmonious adventure” despite the couple’s treacherous journey through the health-care system. Her husband died in 2012.
The NAMSS Board of Directors and the Executive Committee of the AHLA, American Health Lawyers Association , have approved an exciting joint initiative allowing NAMSS members access to a network of 11,000 health lawyers.
NAMSS members can now join the AHLA organization and their Medical Staff, Credentialing and Peer Review Practice Group (MS/CPR) at the discounted rate of $110 for annual membership.
Established to help bridge the relationship gap between MSPs and the legal staff who represent their facilities, this partnership will provide a platform for NAMSS members to have open dialogue with legal staff and exchange information about the regulatory issues affecting hospitals and credentialing departments across the country.
The Joint Commission is developing a Patient Blood Management certification program for Joint Commission-accredited hospitals. Patient blood management incorporates a patient-centered approach into the blood utilization activities and blood conservation strategies that occur within the hospital. Blood conservation strategies minimize the need for blood transfusions.
Patient blood management applies to all patient populations from pediatrics to geriatrics. It also spans the entire continuum of patient medical care, including the management of anemia, minimization of blood loss, and optimization of coagulation, in addition to evidence-based transfusion.
The proposed standards are open for comment until October 10, 2013.
Guest Post. In these days of social media and automatic bill pay, Hillel L. Presser, Esq. offers some worthwhile tips for all of us.
Asset Protection Lawyer Offers 3 Steps to Take Now
Now, you really can live forever, but that’s not necessarily a good thing.
Many of your online accounts – from automatic bill payments to eBay – may remain active after you pass away, unless you take steps to ensure they don’t, says attorney Hillel Presser, author of “Financial Self-Defense (Revised Edition), ”
Automatic bill pay, for example, can theoretically keep tapping your bank account long after you’re gone or, at least, until your money is.
“It’s important to make sure your online bank and shopping accounts, even your social media, can be closed out, or that your loved ones are authorized to access them,” Presser says. “You may ask, ‘Why would I care if I’m gone?’ I can tell you from experience: because it can create real headaches, and more heartache, for your family.”
Bank and shopping accounts will be vulnerable to identity theft, which would affect your estate if someone opens credit cards in your name. You might have valuable intellectual property, like domain names. They may need access to your health records, particularly if you died under questionable circumstances, he says.
There’s the sentimental stuff – photos and emails — that your family may want as a remembrance of you, and the libraries of music and ebooks, which may represent a considerable investment on your part.
“The problem is, even if you provide a family member with all of your accounts, log-ins and passwords, they may not be legally allowed to access them,” Presser says. “In many cases, they may be violating the accounts’ terms of service or violatingfederal privacy and computer fraud laws. Some states have laws governing online materials, but they’re different and which of your accounts are covered depends on where the provider is located.”
What can you do to ensure your family isn’t left with a virtual nightmare after your passing? Presser offers these tips:
• Create a list of all of your accounts, including log-innames, passwords, and answers to any security questions. Obviously, your list will need to be securely stored. Since you’ll need to update it regularly as you add accounts or change passwords, it will be easiest if you keep the list on your computer in a password-protected folder. Some versions of Windows allow you to create protected folders, but you may need to get third-party software to do this, such as freeAxCrypt. Remember to create a backup of your list, whether it’s on a jump drive or printed out on paper. Store the backup in a secure place such as a safe deposit box. Do not put password information in your will, which is a public document.
• If you have a Google account, set up the new inactive account manager. In May 2013, Google became the first site to give users an option for choosing what becomes of their content if they should become debilitated or die. Under the profile button, click “Account,” scroll down to “Account Management,” and you’ll find instructions for “Control what happens to your account when you stop using Google.” You can select how long the account should be inactive before your plans are set into motion; choose to whom you want to offer content, such as YouTube videos, Gmail, Google+ posts, Blogger and Picasa web albums, or whether it should simply be deleted.
• Appoint a digital executor. Perhaps the simplest way to ensure your online life is taken care of is to appoint a digital executor – a tech-savvy person who will be willing and able to carry out your wishes. Authorize the person to access your inventory of log-in information and spell out what you want done with each account, whether it’s providing access to loved ones or business partners, or deleting it.
The digital world has grown and transformed so rapidly, the law hasn’t kept up, which makes managing your digital afterlife challenging, Presser says.
“Until there are more consistent laws and procedures governing this area, it’s best to plan ahead, leave clear instructions and be sure you have a list of accounts where your estate lawyer or a loved one can find it and access it,” he says. “It will make a world of difference to your survivors.”
About Hillel L. Presser, Esq., MBA
Hillel L. Presser’s firm, The Presser Law Firm, P.A., represents individuals and businesses in establishing comprehensive asset protection plans. He is a graduate of Syracuse University’s School of Management and Nova Southeastern University’s law school, and serves on Nova’s President’s Advisory Council. He is a former adjunct faculty member for law at Lynn University. Complimentary copies of “Financial Self-Defense” are available through
Conventional wisdom may lead you to believe you’ll fare better (during surgery) if you get a transfusion, but that’s not always the case, said Colleen Koch, MD, vice chair for research and education in cardiothoracic anesthesiology at the Cleveland Clinic in Ohio. In fact, heart surgery patients who receive blood transfusions tend not to do as well as those who don’t receive them, Dr. Koch noted.
During a coronary artery bypass graft (CABG) surgery, for example, a patient at one hospital might be given two units of blood, while doctors at another center may decide not to give a similar patient a blood transfusion.
Before you head to the operating room, it’s smart to ask your medical team about the likelihood of needing a blood transfusion and whether it can be avoided.
Read the rest of Questions to Ask About Blood Transfusion and Heart Surgery to see questions to ask prior to surgery.
“Physicians have the highest suicide rate of any profession. In the United States we lose over 400 physicians per year to suicide. That’s the equivalent of an entire medical school. Even that’s an underestimate because many physician suicides are incorrectly identified as accidents.”
So states Pamela Wible, M.D. in her article, What I’ve learned from saving physicians from suicide .
In the article she quotes a Canadian doctor who shares her frustration with the practice of medicine. “My head is exploding from banging it against the system.”
If you suspect a physician you know is suffering, reach out; there is help available.
Working your way through the large CMS Provider Charge Data file will take a bit of time and effort, but it’s certainly a gold-mine of comparitive costs. Charges for the top 100 DRGs with and without major complications / comorbid conditions, is searchable across locations and organizations. Downloadable as an Excel or comma delimited file.